Morning Report

November 10th , 2015

Supervisor : dr. Gede Made

Punarbawa, Sp.OG(K)
Medical Students :
Dede, Dila, Nita, Dhani, Farid,
Sobri
CASES RESUME
NORMAL
LABOR

(-)

PATHOLOGY 1.G2P1A0L1 40-41 weeks S/L/IU head

LABOR
presentation with oligohydramnion
2.G3P0A2H0
43
weeks
S/L/IU
head
presentation with BOH

Case Report

Name
: Mrs. M
RM
: 56 95 30
Age
: 22 years old
Address
: Lingsar
Admitted : 8th November 2015 at
08.53 WITA

TIME

SUBJECTIVE

08/11/2
015

Patient referred from Akasia Klinik to

VK IGD NTB GH with G3P0A2L0 1820 weeks S/IUFD/IU. Patient 4
months pregnancy confessed dindnt
fell the fetal movement since 1 weeks
ago, abdominal pain that spread to
flank (-), water leaked from her womb
(-), bloody slim (-).

08.53

history of DM (-), HT (-), asthma (+),

alergi (-)
LMP : 15 05 - 2015
EDD : 22 02 2016
GW : 25-26 weeks

OBJECTIVE
General Status :
GC : well
BP : 120/80 mmHg
PR : 82 bpm
RR : 20 bpm
Temp : 36,5oC
Eye : palor (-/-), icteric (-/-)
Cor : S1S2 single regular, murmur (-),
gallop (-).
Pulmo : vesicular (+/+), wheezing
(-/-), ronkhi (-/-).
Abdomen : scar (-), striae (+), linea
nigra (+).
Extremity : edema (-/-), warm acral
(+/+).

History of ANC : 6x at PHC and

posyandu
Last ANC : 06/11/2015
Result : BP 110/70, BW 63 kg, GW
17-18 weeks, UFH 1 finger below
umbilicus, ballotement (+), FHB (+)
History of USG : 1x at Sp.OG
Last : 05/11/2015
Result : Fetal S/IUFD/IU 16-17 weeks
FM (-), FHB (-)

Obstetrical Status :
Leopold : cant perform
UFH : as the umbilicus
UC : FHB : Ballotement (+)

History of family planning : Next family planning : -

Lab :
Hb 12,2
WBC 10,45
PLT 297
BT 145
CT 512
HbsAg (-)

Obstetrical History :
1.Abortus 3 months curretage
2.Abortus 2 months curretage
3.This

VT : 1 cm, eff 10 %, amnion (+),

impapable small part of fetus and
umbilical cord

ASSESSMENT
G3P0A2L0 25-26
weeks S/IUFD/IU
with BOH

PLANNING
DM Planning :
Diagnostiik
Lab (Dl, BT, CT,
HbsAg)
Therapy
Observation
mother well
being.
Obs. Inpartu sign
Suggest mother
to at and drink
Pro termination
with misoprostol
induction
09.00
DM co to GP, GP
to SPV advice :
Insertion
misoprostol by
the vagina
tablet per 6 hours
At 06.00 before
patient had take
gastrul

TIME

SUBJECTIVE

OBJECTIVE

ASSESSMENT

PLANNING

Pelvic score (total) : 3

Dilatation 1cm (1), cervix length 2cm(1),
station H0(0), consistency rigid (0),
position middle (1)
12.00

Insertion of
misoprostol tab

14.00

GC : well
BP : 110/70 mmHg
PR : 80 bpm
RR : 22 bpm
Temp : 36,8oC
UC : VT : not perform

G3P0A2L0 25-26
weeks S/IUFD/IU
with BOH

- Obs mother well

being suggest
mother to eat
and drink
- Obs for vaginal
delivery

18.00

GC : well
BP : 120/70 mmHg
PR : 84 bpm
RR : 20 bpm
Temp : 36,5oC
UC : VT : not perform

G3P0A2L0 25-26
weeks S/IUFD/IU
with BOH

Obs mother well

being
Insertion of
misoprostol
tab

00.00

9/11/20
15
06.00

Insertion of
misoprostol
tab
GC : well
BP : 110/70 mmHg
PR : 88 bpm
RR : 19 bpm
Temp : 36,4oC
UC : VT : not perform

G3P0A2L0 25-26
weeks S/IUFD/IU
with BOH

Obs mother well

being
Dm co to GP,
GP co to SPV,
advice increase
misoprostol dose
be 1 tab/6hours

TIME

SUBJECTIVE

12.00

18.00

Patient confessed abdominal

pain still seldom

OBJECTIVE

ASSESSMENT

PLANNING

GC : well
BP : 110/80 mmHg
PR : 92 bpm
RR : 21 bpm
Temp : 36,3oC
UC : VT : dilatation 1cm, eff 10%, amnion (+),
palpable part of fetal or tissue

G3P0A2L0 25-26
weeks S/IUFD/IU
with BOH

- Obs mother well

being suggest
mother to rest
well, eat and drink
- Insertion of
misoprostol
1tab/6hours

GC : well
BP : 110/70 mmHg
PR : 96 bpm
RR : 22 bpm
Temp : 36,5oC
UC : 2x10-15
VT : dilatation 1cm, eff 10%, amnion (+),
palpable part of fetal or tissue

G3P0A2L0 25-26
weeks S/IUFD/IU
with BOH

-Obs mother well

being suggest
mother to rest
well, eat and drink
- Insertion of
misoprostol
1tab/6hours

19.00

Patient confessed water leaked

from her womb

GC : well
BP : 110/70 mmHg
PR : 84 bpm
RR : 20 bpm
Temp : 36,7oC
UC : 4x10-45
VT : dilatation 4cm, eff 50%, amnion (-),
hodge II, palpable part of fetal

G3P0A2L0 25-26
weeks S/IUFD/IU
with inpartu
active phase of
labor + BOH

-Obs mother well

being suggest
mother to eat and
drink
-Obs progress of
labor

19.12

Mother wants to bear down

Inspection : bulging perineum, opening

vulva, anus pressure

Second stage of
labor

Conduct labor
Baby was born at
19.15 death,
male, BW 300gr,
BL 21cm,
Maseration grade
III

TIME
19.20

SUBJECTIVE

OBJECTIVE
GC : well
BP : 100/60 mmHg
PR : 76 bpm
RR : 22 bpm
Temp : 36,7oC
UC well
UFH 2 fingers above symphisis
Bleeding about 50cc
Perineum intact

ASSESSMENT

PLANNING

3rd phase of
labor with IUFD +
suspect rest
placenta

- Injection oxytocin
1amp IM
- placenta was
born spontan not
complete, doing
exploration
- UC well
- UFH 2 fingers
above symphisis
- Bleeding about
50cc
- Perineum intact
- suggest mother
to eat and drink
-DM co to GP, GP
co to SPV advice :
pro USG
tomorrow morning

21.00

GC : well
BP : 120/80 mmHg
PR : 80 bpm
RR : 19 bpm
Temp : 36,8oC
UC well
UFH 2 fingers above symphisis
Active bleeding (-)

2 hours post
partum with IUFD
+ suspect rest
placenta

- Obs UC,
bleeding, mother
well being
- Suggest mother
to rest well, eat
and drink

TIME
10/11/2
015
06.00

SUBJECTIVE

OBJECTIVE
GC : well
BP : 110/70 mmHg
PR : 84 bpm
RR : 18 bpm
Temp : 36,6oC
UC well
UFH 2 fingers above symphisis
Active bleeding (-)

ASSESSMENT

PLANNING

1 day post
partum with IUFD
+ suspect rest
placenta

- Obs mother well

being, UC,
bleeding
- Suggest mother
to eat and drink
- Pro USG this
morning